RBCCV Brazilian Journal of Cardiovascular Surgery Revista Brasileira de Cirurgia Cardiovascular

Utilizing equipment and conditions similar to the operating room we have reproduced all that it is necessary for simulating cardiac surgery with extracorporeal circulation. Surgeries are performed in a dummy who has a freshly fixed human anatomic piece firmly attached to a device specially developed and which is placed inside the thorax of the dummy. The procedures performed are videotaped and are also displayed simultaneously in a large screen situated in an auditorium with free communication with the surgical team. The system was utilized in July 1993 - XI Unicor International Symposium, and in November 1993 - 3rd SCICVESP Congress and in March 1994 - 21th Brazilian Congress of Cardiac Surgery with the following procedures being perfomed: Senning, Jatene, cavo-pulmonary anastomosis, Konno, Monaghian, mitral valve replacement, labyrinth surgery, retrograde cardioplegy, implantable defibrillator and orthotopic heart transplantation.The method was received enthusiastically by our colleagues and proved to be an efficient teaching technique as well as an excellent rehearsal tool due to its: 1) perfect reproducibility of the surgical conditions; 2) excellent image of the procedures as viewed in the large screen at the auditorium; 3) improvement in the way surgery is learned and taught due to the fact that the surgical field is clear cut and the surgical team is relaxed; 4) interruption of the surgical act without the complications that could develop during a "real" surgery; "surgery" can be interrupted at any time; 5) obtaining a video library with high quality definition images of different procedures; 6) we can foresee a frozen archive of hearts with congenital or acquired heart defects prepared to undergo surgical correction and 7) the future utilization of this technique in other surgical specialties.

Keywords: heart surgery, methods. surgery, operative methods. cardiac surgery, teaching.

From January 1980 to december 1992, 301 patients underwent mitral valve repair in Heart Institute of HCFMUSP. Mean age of the patients was 37.96 years, with standard deviation of 21.4 years and 151 (50.2%) were males. One hundred and twenty eight (42.52) patients presented symptons of rheumatic fever disease, 78 (25.91%) had degenerative valve disease, 21 (6.97%) were congenital, 18 (5.98%) were ischemic, 9 (2,99) had endomyocardial fibrosis, 8 (2.65%) had bacterial endocardis, 5 (1.66%) had chronic valvulitis, and 34 (11.29%) had no defined ethiology. Two hundred and four (67.8%) patients had mitral insufficiency and 97 (32.2%) double mitral lesion. Associated procedures were performed in 45% of the patients, the most frequent was aortic valve replacement in 41 (13%) patients. Merendino type annuloplasty was performed in 97 (30.99%) patients. Carpentier ring annuloplasty in 93 (29.71 %), and posterior sling in 76 (24.28%) patients. There were 12 operative deaths (3.9%). Three (0.9%) patients were reoperated upon in the immediate postoperative period due to valve disfunction. Linearilized rates of thromboembolism, late death, re-repair, and valve replacement were 0.2%; 0.5%; 1.0%; and 1.1% per patient/years, respectively. The actuarial survival rate at 12 years was 83.6% and the actuarial freedom from reoperation was 83%. Seventy nine percent of the patients were in NYHA class I at the last follow-up (evolution time was 10077 months/patients). We concluded that patients submitted to mitral valve repair presented satisfactory clinical evoluation.

Keywords: heart valves, mitral, surgery. heart valves, mitral, plastic repair.

From September 1984 to December 1992, 145 selected patients underwent mitral valve replacement using cadaver aortic valves obtained during rotine autopsy, processed in glutaraldehyde and mounted into flexible stents made of Celcon and covered with Dacron fabric. Mean age was 22.5 years, ranging from 5 to 77 years and 54.5% (79 patients) were 15 years old or younger. Twenty patients (13.8%) had undergone previous mitral valve replacement using porcine, bovine pericardial and dura mater valves, which were calcified. Six patients had undergone a previous mitral valvuloplasty. Hospital mortality (30 days) was 2.1% (3 patients). It was collected 709 patient-years of total follow-up, corresponding to a mean follow-up of 5 years per patient. The longest follow-up was 9 years and 5 months. Late complications related to the allograft were present in 48 patients, including fibrocalcification, thromboembolism, endocarditis and peri-valvular leak, corresponding to an incidence of 6.8% ± 0.9% per patient-year. Fibrocalcification was the most important late complication, and it was observed in 37 patients, representing an incidence of 5.2% ± 0.8% per patient-year. All patients who developed calcification in the implanted valves were 15 years old or younger. Calcification developed from 14 to 100 months after implantation and the mean interval between valve insertion and calcification was 46 months. Reoperations were performed on 44 patients, and the allobioprosthesis was replaced in 30 of them. The incidence of reoperation was 6.3% ± 0.9% per patient-year. There were 15 late deaths with a mortality rate of 2.1 % ± 0.5% per patient-year. Only 3 deaths were valve related. The 10-year acturial survival was 82.9% ± 4.8%. The overall 10-year freedom from valve dysfuntion due to calcification was replaced in 30 of them. The incidence of reoperation was 6.3% ± 0.9% per patient-year. There were 15 late deaths with a mortality rate of 2.1 % ± 0.5% per patient-year. Only 3 deaths were valve related. The 10-year 62.1 % ± 11.2%; for patients 15 years old or younger was 24.2% ± 11.2%, and it was 100% for patients older than 15 years. Although fibrocalcification has remained the most important late complication observed in the pediatric age group and the main cause for reoperation, its incidence was much lower than the calcification rate reported in the literature for xenobioprostheses in young patients.

Keywords: heart valves prostheses, biological. valvar substitutes.

In the cardiomyoplasty, the contraction of the skeleton muscle, undergone electric stimulation on the dilated ventricle wall, increases the ventricle function, which is dependent of the heart and the base disease previous conditions. One of the main problems which interferes with the sucess of the cardiac muscle replacement is the myocardial synchronic stimulation and the skeleton muscle. The stimulation of this muscle in long-term has been possible because of the special electrodes associated with the sequential progressive stimulation, adjusting it to the cardiac function, through the gradual transformation of glicolitic fibers exposed to fatigue in highly resistant slow oxidizers. The pulse generator Myos (Biotronik) has been used in our center for electrical stimulation of the latissimus dorsalis in synchronization with the myocardium. This electronic circuit and lithium battery type of cardiomyostimulator stores a stimulation program responsible for different operational modes, adapted by acomputer program. In order to program the cardiomyostimulator, the moment of the pulse synchronization with the aortic valve opening is extremely important. The high velocity M mode is utilized to evaluate the synchronism. The cardiomyoplasty clinical evaluation is based on the results obtained from 32 patients at 22 ti 72 years old (average=46.2 years) most of patients (72%) presented dilated myocardiopathy due to undetermined cause, 24% of chagasic origin, 3% virus and 3% due to peripartum. Hospital and late mortality rate were both 12.5% and 3.1% and 3.7% respectively, excluding the chagasic patients. The actuarial survival was 81.3 + - 0.22% after 6 years and 94.4 + - 0.1 % after 5 years, withdrawing the chagasic patients. The average indexes of systolic diameters (55,1 mm), diastolic (70,7 mm), segmental shortening (22.8%) and ejection fraction (51.0%), related to an average follow-up of 14.2 months, reflect that the cardiomyoplasty can be effective to assist the left ventricle. Choosing the right patient seems to be key to the goog operative result in short and long terms.

Keywords: cardiomyoplasty. cardiomyostimulator. latissimus dorsalis.

The authors propose the treatment of aortic aneurysms by using an intraluminal graft. A new device which transforms any kind of graft of different sizes and diameters into an intraluminal one is described. This new device just needs an extra-vascular circunferential ligature and does not require any fixation suture. The use of the rigid, sulcated DELRIN (R) ring simplifies the technique shortening the duration of the surgery, reducing surgical bleeding and dispensing the use of profound hypothermia and platelet transfusion. Between May 1989 and January 1993, 22 patients were submited to aneurysmectomy of the aorta using this technique. Twelve patients exhibited acute aortic dissection (type I and II DeBakey), one DeBakey type III acute aortic dissection, two presented descending aortic aneurysm, two cases were of thoraco-abdominal aortic aneurysm and five aneurysms of abdominal aorta. Three patients died in the imediate post-operative period from cerebrovascular accident, mesenteric thrombosis and pulmonary infection. The survivors have been followed up as outpatients.

Keywords: aneurysms, aortic, intraluminal graft, surgery.

From May 1990 to January 1994, one hundred and twenty (120) patients underwent aortic valve replacement with the use of the porcine aortic stentless valve. This group comprised of eighty-three (83) male and thirty-seven (37) female patients. The age ranged from eleven (11) to seventy-six (76) years with a mean of 36. There were 85 patients under 40 years of age. Sixty-four patients (64) underwent their first aortic valve replacement due to rheumatic heart disease, thirty (30) because of prosthetic valve failure and of those: twenty (20) due primary tissue failure and in ten (10) due to prosthetic endocarditis, native aortic bicuspid valve in eleven (11) and senile calcificant aortic valve disease in four (4). Thirty-three (33) patients had aortic annular related pathology. The functional class revealed sixty-one (61) patients in class III and fifty-nine (59) in class IV. The longest follow-up was 42 months with a mean of 26. The surgical technique used in the aortic valve surgery rendered consistent and reproducible results. The hospital mortality was 5% (6 patients). This mortality was not valve related. The hospital morbidity revealed full recovery of all patients. There were four (4) late reoperations, in two (2) due to recurrent endocarditis and in two (2) because of paravalvar leak. All patients had full recovery after the reoperation. There was a late mortality of six (6) patients (non valve related). The follow-up of these patients revealed full competent valve in ninety-seven (97) patients and only minor jet in nine (9). Most patients are in functional class I and II. The stentless concept has proven to be outstanding in the aortic position throughout the current follow-up. Although the test of time is required, we have gained confidence in the procedure due to the good clinical results.

Keywords: heart valves prostheses, aortic.

The purpose of this study was to analise late anatomical status of coronary arteries in patients (pts) in whom orthotopic heart transplantation(OHT) was perfomed. We studied 22 pts submitted to OHT with post-operative follow-up longer than 36 months. They were evaluated by cinecoronariography every year in a 5 years follow-up. Ventriculography analisis showed stability (in normal values) of the left ventricular ejection fraction (p= 0,99) during the follow-up period. The sequential coronary studies showed a progressive increase on incidence of abnormalities in coronary arteries with disorders of contratile function. The obstructive abnormalities were present in all segments but more in distal territories. The acute rejection episodes and cardiomiopathy etiologies didn't change the natural evolution of coronary atherosclerosis.

Keywords: heart transplantation, follow-up, coronary arteries. heart transplatation, coronary atherosclerosis. heart transplantation, orthotopic.

Bovine pericardial (P.B.) grafts are in clinical use at Biocor Institute since 1989 for replacement or repair of the ascending aorta (AsAo) and the initial segment of the aortic arch (AoAr); the main advantages of B.F. grafts that justified its clinical application are: easiness to handle, fully hemostatic and low cost. This study was conducted to analyse the fate of the heterograft after a minimum of 2 years of implantation. From February 1989 to Frebruary 1994, 84 patients had a B.P. graft implanted in the AsAo or AoAr. The total hospital mortality was 18%. Thirty-one patients who had two years of follow-up were selected for analysis of the B.P. graft (mean follow-up = 40.9 months). They underwent either an echocardiographic examination or an aortographic study (n=15) in order to determine the presence of dilatation, calcification, thrombus and pseudoaneurysm. In all patients the graft was functioning perfectly and no abnormalities were recorded. The current follow-up is short and complications such as calcification and pseudoaneurysm may still develop, therefore a longer time is required. The present study has shown superior handling and hemostatic properties over the classical Dacron grafts and no adverse behavior was noted during this 4 years of study.

Keywords: ascending aorta, surgery. aortic arch, surgery. pericardial grafts, surgery.

The technological advances of recent years have permitted a wide range of uses for intraaort balloon pumping (IABP) to support acute cardiac failure in many clinical condition. In spite of this, some complications related to its insertion, duration of use and location have been described. The aim of his study was to investigate the incidence of infections in severely compromised postoperative cardiac patients undergoing IABP therapy. Between January 1990 and July 1992, the records of 97 patients that required IABP support after cardiac surgery were reviewed, but only 55 met the criteria to be included. The analysis consited of: incidence of infections, culture results, type and duration of by-pass and surgery duration of intravascular catheterization and clinical outcome. The following sites of infection were considered: lung, urine, blood, surgical incision and IABP catheter insertion. The mean time of procedures were: IABP= 3.9 ± 2.01 days surgery an by-pass equal to 8.0 and 2.5 hours respectively. We observed a high incidence of infection in these patients, mainly pneumonia (63.6%). The IABP insertion infection rate was 7.0% higher than our general postoperative wound infection rate (3.0%). Although this relatively higher incidence of infection may not directly relate to the martality rate, we suggest that these patients must have extremely careful surveillance for ocurrence of infections and possible prophylactic measures regarding pulmonary infections.

Keywords: intra-aortic balloon pump, complications, infectious. counterpulsation in heart surgery.

From March 1990 to January 1994, 17 patients 1 to 13 years old (mean 7 years), who had congenital heart disease with functional isolated ventricular chamber, were submitted to bidirectional cavopulmonary shunts. Nine cases had Tricuspid Atresia (TA) (7 type Ib, 1 type Ic and 1 type IIb). Five cases had Double Inlet Right ventricle (Dl RV); two cases had multiple Ventricular Septal Defects (VSD) plus RV hypoplasia. One case had pulmonary atresia with Intact Ventricular septum (PA/IVS). Nine (52,9%) patients had been submitted, to previous paliative operations. The operations in 12 (70,5%) cases were with extracorporeal circulation (ECC) and in 5 (29,4%) cases with superior vena cava (SVC) to right atrio (RA) temporary shunt. In all cases the SVC was anastomosed to right pulmonary artery (RPA) closing the pulmonary valve (PV) or linking the Blalock-Taussig shunt to interrupt the pulmonary flow. There are three (17,6%) deaths in the immediate postoperative period and 2 (14,2%) late deaths. Twelve (70,5%) patients were followed-up for 2 to 46 months. One patient was submitted to the 2 nd operation, tunnelating the inferior vena cava (IVC) to RPA, with success. The assessment of bidirectional cavopulmonary flow was made with Doppler echocardiography and magnetic resonance and the pulmonary perfusion was made with radioisotopic cintilography. The indication tor the 2 nd, operation depended on the clinical evolution and assessment of arterial saturation during the cicloergometric test. The bidirectional cavo pulmonary shunt allows the progressive adaptation of the venous flow to lung and reduced ventricular volume load, preparing the patient to total venous shunt.

Keywords: cavopulmonary shunt, surgery.

The authors have used for spinal cord protection during descending aortic surgery, partial extracorporeal circulation from left atrium to left femoral artery, low dose of heparin (1 mg/kg), centrifugal pump (bio-pump) and controlled exsanguination. They have operated upon with this methodology 4 patients without mortality, paraplegia or excessive bleeding.

Keywords: spinal protection in aortic surgery. extracorporeal circulation. exsanguination.

The aim of this study was to analyze the early and late results of the reoperation for valvar disease with the focus on the patient not on the prosthesis. A retrospective analysis of 697 patients (419 female, 278 male) was done between 1970 and 1990. The mean age was 43.4+17.9 years old. Pre-operative diagnosis were 281 (40.3%) prosthesis dysfunction, (2/2) 30.5% restenosis pos-comissurotomy, (103) 4,7% prosthesis rupture, 101 (14.5%) prosthesis thrombosis. Reoperations for valvopathy were 7.38% of the total surgical procedures in our Service, and in the last 2 years 26.7% of the total valvar surgery procedures. The hospital mortality was 9.89%, and the mean interval between the first and second procedure was 77+37 months. A third operation was carry on 110 patients with the mean interval of 81+28 and 10 had a fourth intervention. The late mortality was 16.6% and the mean follow up is 14 years with 18.7% lost of segment. Different from others studies where the prosthesis have been followed, our main goal was followthe patient's clinical evolution. The results shown that reoperations for valvopathy have increased in our Institution. The procedure can be done with an acceptable risk even though the long term results are not excellent the patients can have a reasonable survival and a chance of a new operation.

Keywords: heart valves, surgery. heart valves, reoperation. valvopathies, follow-up of patients.

This subject is extensive, and will be divided in three parts. The present paper is related to historic aspects, surgical indication, preoperative approaches and heart valves prostheses. The following two chapters will discuss surgical techniques, reoperations and special condicions like surgical treatment of endocarditis, and bovine pericardial valves.

Keywords: heart valves, surgery. valvopathies, history. valvopathies, surgical indications. valvopathies, clinical approach. heart valves prostheses.

Anxiety has been mentioned as one of the relevant agents for the development and maintenance of coronary artery disease. In this study were evaluated the levels of State - Trait Anxiety of 100 patients assisted by the Service of Cardiovascular Rehabilitation of Instituto Dante Pazzanese de Cardiologia, São Paulo, Brasil. Patients were submited to the State-Trait Anxiety Inventory - STAI before physical activities, those who showed State Anxiety above the average were revaluated after the activities, to verify if the activities helped to diminish the levels of State Anxiety. The conclusion given from the results was that the patients benefited from this procedure, considering the decrease of anxiety levels studied. Hostility and sociability also stood out as ways of interrelations. Psychologicaly speaking, the authors suggest that the use of relaxing technics, group dynamics and psychological guidance as means to change the behavior and the life style of an individual, help to establish a better psychism functioning as well as a homeostasis balance.

Keywords: coronary diseases, psicological profile of patients. coronary diseases, rehabilitation.

Epicardial fetal pacing via thoracotomy has the potential for being a safer and more reliable procedure to treat congenital complete heart block (CHB) associated with fetal hydrops refractory to medical therapy. To assess the acute electrophysiologic characteristics of two ventricular epicardial leads, a new experimental model of fetal heart block induced by cryosurgical ablation of the AV node without the need for fetal cardiac bypass was performed in 12 pregnant ewes at 110-115 days of gestation. A modified screw-in lead (one and a half turn) was used in 6 fetal lambs and a stitch-on lead in the other 6 lambs. CHB was achieved in 100% of the fetal lambs, with no ventricular escape rate noticed in any of the lambs. The acute stimulation thresholds were consistently low for both the leads, with lower values for the screw-in lead at pulse duration below 0.9 ms (p < 0.03). Current measured at voltage threshold with pulse width below 0.5 ms was lower for the screw-in lead (p < 0.048). Stimulation resistance, measured during constant-voltage pacing, was not statistically different between the two leads (441.8 ± 13.7 Ω for the screw-in lead versus 480.2 ± 59.2 Ω for the stitch-on lead). No significant differences (p > 0.20) were found in R-wave amplitude between the two electrodes. Slew rates were significantly higher with the screw-in group than with the stitch-on group (1.40 ± 0.2 versus 0.62 ± 0.2 V/s, p=0.04). This model of CHB is a simple and reproducible method to assess fetal pacing. We find the screw-in electrode a better option when fetal pacing is indicated.

Keywords: fetal cardiology. fetal heart block. fetal surgery. fetal arrhythmias. fetal pacing.

BACKGROUND: Epimyocardial pacemaker leads has been progressively given-up due to poorer results in comparison to endocardial pacing. Transthoracic transatrial endocardial lead placement has been described to avoid epicardial pacing in special situations. Permanent pacing associated to open heart surgery is a special situation when epicardial leads have been implanted at the same procedure or endocardial leads have been inserted with an independent approach. OBJECTIVE: To propose transatrial endocardial pacemaker in cases of concomitance of permanent pacing and open heart surgery and to report our experience with this technique in 6 patients. MATERIAL AND METHODS: From July 83 to August 94, 6 patients, 5 to 64 years old, 4 male and 2 female, were submitted to open heart surgery for aortic valve replacement (4), Chaga's disease left ventricular aneurysm resection (1) and atrioseptoplasty and pulmonary valve comissurotomy (1 patient). At the same procedure, atrioventricular (5) or atrial (1 case) pacemaker were implanted. The surgical technique consisted in stablishing cardiopulmonary bypass with two separated vena cava canulas and, under cardioplegic arrest, to correct the cardiac defect and to implant the leads through a rigth atriotomy, at the same procedure. AH the 6 patiens received atrial endocardial lead while only 4 patients were submitted to ventricular endocardial implantation. The pulse generators were implanted in the infra-clavicular region in the 4 male adults, in the submammary position in the woman and in the abdominal wall in the child. RESULTS: Intra-operative measurements showed excellent conditions for pacing and sensing. No peroperative complication occurred. After a 4 to 137 months follow-up period no complications related to the pacemaker were observed. CONCLUSIONS: The authors conclude that transatrial endocardial pacemaker implantation may represent a good option to avoid epicardial leads or two independent procedures when permanent pacing is associated to open heart surgery.

Keywords: pacemakers, cardiac, surgery. cardiac stimulation, artificial, pacemakers.

OBJECTIVE: To present a number of modifications to the conventional heart implant technique in orthotopic cardiac transplants. METHODS: The proposed modifications consist basically of the following: 1) resecting as much of the disease heart as possible during the cardiectomy, leaving only sufficient tissue to enable the new heart to be sutured during the implant; 2) opening the right atrium of the donor heart from the inferior vena cava, close and parallel to the interatrial septum as far as the highest part, where the incision should be sharply directed towards the right atrial apendix; 3) initiating the implant through the pulmonary artery, and 4) suturing the atria simultaneously, in a single plane, atthe level of the septum. These technical modifications have been utilized in all patients undergoing transplants in the three Institutions. REMARKS: The technical changes present the following advantages: 1) a perfect alignment of the pulmonary artery, thereby avoiding bending and torsion and 2) smaller atrial cavities with no sutures protouding into the atria and, consequently, less likelihood of tromboembolic phenomenon or asynchronous contractions of the atria (donor-receiver) which, in addition to facilitating the formation of thrombi, may impair the functioning of the atrioventricular valves. CONCLUSIONS: The method is easily reproducible and can be recommended for orthotopic heart transplants.

Keywords: heart transplantation, orthotopic.

The surgical approach to coronary artery disease has improved a lot during the past two decades. With the widespread use of balloon angioplasty, a growing percentage of surgical patients, have complex coronary pathology. In properly selected patients, coronary endarterectomy has been a valuable adjunt to bypass techiniques by removing obstructing lesions and preparing the distal artery for bypass grafting. Over a 5 years period (1988 to 1993), 2781 patients underwent surgical revascularization at our Instituition (Hospital do Coração). Coronary artery bypass combined with coronary endarterectomy was done in 110 patients. There were 99 men (90%) and 11 women, mean age 58.9 years. For comparation patients were placed into two groups: Group A, patients undergoing endarterectomy to one artery, 104 patients - 94.5%. Group B, patients with more than one endarterectomy - 6 patients 5.4%. Perioperative myocardial infarction envolving the area supplied by the endarterectomized artery occurred in 6.3%, (7 patients). In 3 (2.7%) the infarction was not related with the endarterectomized artery. Complications during the post-operative period were: arrhythmia in 26 patients (23.6%), return to the operation room for control of bleeding in 12 (10.9%), acute renal failure in 10 (9%), and low cardiac output in 4 (3.6%) patients. Operative mortality rate was 4.5% (5/110), due to low cardiac output and multiple organs failure; 4 (3.8%) patients belonged to Group A and 1 to Group B (16.6%). This study demostrates that multiple bypass grafting and adjunt coronary endarterectomy, can yeld good clinical results in patients with difuse coronary artery disease, many of whom would otherwise be inoperable.

Keywords: coronary artery, revascularization, surgery.

This second part will cover operative technique, postoperative approach and reoperations of valvopathy patients. In Operative Technique, there is the description of the anesthesia procedures, surgical approach which includes the assembling of the extracorporeal circulation and surgeries of mitral, aortic, tricuspid and pulmonary valves. In the Postoperative Approach, the routine in the Intensive Care Unity is reported, and in Reoperations the surgical technique is covered.

Keywords: heart valves, surgery. valvopathies, operative techniques. valvopathies, postoperative approach. valvopathies, reoperation. heart valves prostheses.

All patients aged > 80 years which underwent myocardial revascularization at the InCor Institute were analized in order to establish the evolution of surgical treatment of coronary artery disease. From the total of 79 patients, 60 (75.94%) were male and 19 (24.05%) female. The mean age was 82.33 (80 to 90) years. The symptons presented to indicate surgery was unstable angina in 56 (70.88%), stable angina in 22 (27.84%) and 1 (1.26%) patient was operated on after angioplasty. The autogenous saphena vein was the surgical approach in 69 (87.34%) patients while in 10 (12.5%) was the mammary vein. The present total nosocomial mortality rate reaches 6.32%. It has been decreasing at the Institution from 13.33% in 1990 it came down to 8.5% in 1993 presently it reaches 6.32%. Nosocomial causes of death were found to be anoxic encephalopathy, respiratory insufficiency, digestive hemorrhage and cardiogenic shock. Mean time follow-up ranged 18.3 (4 to 83) months. The determinant mortality time was infection, neoplasia, stroke, mesenteric thrombus, depressive syndrome and cardiogenic shock. Considering that: 1) The brazilian population has been getting older with the expectancy of life augmented; 2) The nosocomial mortality for myocardial revascularization in the elderly has been decreasing it is therefore concluded that the surgical treatment represents a good alternative for the octogenarian as it leads to a better quality and expectancy of life.

Keywords: myocardial revascularization, surgery, elderly patients.

This abstract, in three different parts, has presented a briefing on cardiac surgery focusing valve surgiries and valve substitutes successfully used in the 60's at first the mechanical prosthesis, followed by the heterologs afterwards the glutaraldehyde introduction in order to preserve biological tissues. The basic indications to operating on valve lesions consist in symptom relief in preservation of complications and in mortality. Also in the first part, there is description of the surgical indication publication aspects pointing out stenosis and insufficiency of mitral, aortic, tricuspid and pulmonary valves, active inffectious endocarditis and pre-operative procedure in addition to the characterization of different mechanical and biological cardiac valve bioprostheses that exist in the market and their most frequent complications. The surgical treatment in valvopathies, operative techniques to replace mitral, aortic tricuspid and pulmonary valves, anesthetic and post-operative procedure as well as reoperations were covered in the second part of the publication. The abstract was concluded considering particular situations such as surgical treatment in endocarditis in mitral, tricuspid and aortic valves whose tendency is greater than it is in mitral and the most common cause of acute aortic failure as well. The endocarditis development has a different physiopathology when compared to prostheses and native valves, with greater morbi-mortality than that observed in native valves. There are a few endocarditis increasing risk factors in native valves, black race, mechanical prostheses, male sex and long extracorporeal circulation time. The clinical-surgical interaction seems to influence decisively in order to obtain better results in this pathology. Finally our experience has been reported with biological prostheses in mitral and aortic positions in 11 and 10 years of follow-up, respectively. The survival index in mitral replacements was similar amongst youngsters and adults 74% mitral and 67% aortic. Late fatal bioprosthesis related complications in mitral position were rupture, endocarditis, paravalvular leakage, thromboembolism and especially calcification at a rate of 1.0 event % patient-year 95% of the patients free from those complications. In the aortic position, thrombombolism and especially endocarditis were ruled out, amounting to 1.6 events % patient-year (aortic), focusing endocarditis and calcification in mitral and endocarditis and vascular brain stroke in aortic, 55.2% (mitral) and 85.7% (aortic) of the patients free from those complications. Due to the high calcification occurrence, especially among youngsters who underwent bioprosthesis replacement in general, there was a study covering different ages, with bovine pericardium prostheses in mitral position. The results justified the use of this prosthesis even in young patients, as apposed to authors who recommended the use of this graft in patients up to 30 years. It was concluded that bovine pericardium prostheses, when strictly prepared, shows not only a good hemodynamic performance, bur also a late satisfactory evoluation. It is important to consider that a permanent gathering of the literature is fundamental for the community to be aware of the advantages and disadvantages of every prosthesis type available.

Keywords: heart valves, surgery. valvopathies, history. valvopathies, surgical indications. valvopathies, clinical approach. heart valves prostheses.

The authors proposition is to make an experimental study of two methods of cerebral protection to be used during aortic arch aneurysm resection. The methods to be evaluated were profound systemic hypothermia (under 20ºC) whith great vessels occlusion and profound systemic hypothermia with selective right carotid artery perfusion. Two groups of 15 dogs each were submitted either to profound systemic hypothermia with great vessels occlusion (Group I), or to profound systemic hypothermia with selective right carotid artery perfusion (Group II). Serial jugular vein samples for pH and PaCO2 were analyzed to evaluate ischemic cerebral metabolic derangements. Hystopathological studies were also performed 45, 90 and 135 minutes, through animal sacrifice in each experiment. The results have shown good cerebral protection with both methods in the 45 minutes ischemic interval. At 90 minutes Group II method has conferred better cerebral protection than Group I. At 135 minutes of cerebral ischemia neither method could afford cerebral protection against ischemia.

Keywords: cerebral protection. aortic arch aneurysms, surgery.

The authors propose a technical variation that aimes to optimize the aorta diamenter at the site of the anastomosis, obviating the chance of developing fibrosis retraction and intraortic gradients at the long term follow-up. Following the removal of the coartation site, 3 trapezoidal flaps are shaped at each aorta end. These flaps when approached will fit perfectly. These flaps are shaped by 3 identical coinning at each aortic end, and the anastomosis will approached the projection of one end to the recess of the other. The result is a zig-zag sinusoid like suture. Until now 5 patients underwent this technique with age 2 months, 4 months, 10 and 36 years. Three were male. There were no surgical complication. The first case (2 months with associated congenital cardiopathy) had recoarctation in the 9th month of folow up, and required reintervention. This was problably due to technical difficulties or inadequate indication. The proposed technique yelds a large lumen, maybe even larger than the reference diameter at the anastomosis site. Such diameter depends on the flaps depht in each aortic end.

Keywords: aortic coarctation, surgery.

In the period between July 1980 and June 1989,172 consecutive patients were submitted to combined coronary and valvular surgery. There were patients with predominantly valvular indications and others with predominant coronary indications. In 95 cases, myocardial revascularization and surgical treatment of the aortic valve (RAo) were simultaneously performed. Seventy five patients were submitted to myocardial revascularization and surgical treatment of the mitral valve (RMi). The more frequent valvular lesions were aortic stenosis (44 cases) and mitral insufficiency (40 cases). The mean number of anastomoses per patient was 1,87 for RMi cases and 1,56 for RAo patients. Overall hospital mortality was 9,8%; RAo mortality was 7,3% and RMi mortality was 12%. Mortality of patients with ischemic mitral insufficiency operated on electively (20%) or in an emergency basis (37,5%) was not statistically significant (x2=04423). There was not a relationship between mortality and the number of anastomoses per patient. A tendency for better results regarding mortality was observed in RMi patients in which the valve was preserved (x2=1,6382). The survival actuarial curves in 19 semesters demonstrates a valve of 82,6% for RMi patients, 90,4% for RAo patients and 86,3% for the whole series. After evolution of 5172 months/patients, 75% were in functional class I (NYHA).

Keywords: heart valves, surgery. myocardial revascularization, surgery.

The clinical management and the technique used for removal of intracardiac transfixing foreign body (needles) is described by the autors. It consists of manually involving the heart and expression of its inferior wall against the anterior in order to direct the path of the object through the myocardium. Special emphasis is given to the visualization of the site where the object tends to externalize, aiming to prevent the eventual injuries of the coronary arterial system.

Keywords: foreign bodies, intracardiac, surgery for removal.